Pull-out resistance of connected K-wires for osteosynthesis: development of a numerical model.

A predictive finite element model was developed to investigate the best configuration of a fixation pins system consisting of two K-wires inserted in a synthetic model (Sawbones®) at different angles and secured to a connecting rod. Two key parameters were considered to determine the best configuration delivering the higher pull-out strength and lower pull-out length: the diameter and insertion angle. Results show that as the diameter and insertion angle increased, the pull-out force increased, while the pull-out length decreased. Results are successfully compared with available experimental data in literature. This model can be used as an alternative to experimental study.

Does Google's Bard Chatbot perform better than ChatGPT on the European hand surgery exam?

PURPOSE: According to a previous research, the chatbot ChatGPT® V3.5 was unable to pass the first part of the European Board of Hand Surgery (EBHS) diploma examination. This study aimed to investigate whether Google's chatbot Bard® would have superior performance compared to ChatGPT on the EBHS diploma examination. METHODS: Chatbots were asked to answer 18 EBHS multiple choice questions (MCQs) published in the Journal of Hand Surgery (European Volume) in five trials (A1 to A5). After A3, chatbots received correct answers, and after A4, incorrect answers. Consequently, their ability to modify their response was measured and compared. RESULTS: Bard® scored 3/18 (A1), 1/18 (A2), 4/18 (A3) and 2/18 (A4 and A5). The average percentage of correct answers was 61.1% for A1, 62.2% for A2, 64.4% for A3, 65.6% for A4, 63.3% for A5 and 63.3% for all trials combined. Agreement was moderate from A1 to A5 (kappa = 0.62 (IC95% = [0.51; 0.73])) as well as from A1 to A3 (kappa = 0.60 (IC95% = [0.47; 0.74])). The formulation of Bard® responses was homogeneous, but its learning capacity is still developing. CONCLUSIONS: The main hypothesis of our study was not proved since Bard did not score significantly higher than ChatGPT when answering the MCQs of the EBHS diploma exam. In conclusion, neither ChatGPT® nor Bard®, in their current versions, can pass the first part of the EBHS diploma exam.

A Cadaveric Study Examining the Accuracy of Wireless Hand-Held Guided Ultrasound Injections Versus Blind Injections in the Flexor Tendon Sheath.

Purpose: Hand-held ultrasound (HHUS) is gaining popularity among clinicians. Although its use for procedural guidance could have several advantages in hand surgery, other surgeons may wonder about its added benefits. This cadaveric study aimed to examine the hypothesis of increased accuracy of wireless HHUS-guided injections versus that of blind injections into the flexor sheath. Methods: Our series included 20 fresh cadaveric hands with 80 fingers randomly assigned to 2 groups. In group A, 10 hands were randomly assigned to receive a landmark injection and then received a blinded injection to the flexor tendon sheath (FTS). In group B, 10 hands were blinded in the same manner and received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomic dissection was performed to evaluate the injection accuracy based on the dye's filling pattern in the FTS as stage I (no filling), stage II (<50% filling), and stage III (>50% filling). Statistical analysis was performed, and P <.05 indicated a significant difference. Results: One finger was excluded because of severe Dupuytren contracture. In group A, 39 blind injections of the FTS were performed, with 82% (32/39) fingers achieving stage III filling. In group B, 40 ultrasound-guided FTS injections were performed, with 90% (36/40) of fingers achieving stage III filing. Our study did not reveal any superiority in accuracy when ultrasound guidance was used (P = .35). Conclusions: Hand-held ultrasound-guided FTS injections were not more accurate than blind injections performed by an experienced hand surgeon. These findings suggest that blind injections can be used as routine practice when performed by experienced operators to treat trigger finger. However, the use of HHUS may offer other advantages in hand surgery practice. Clinical relevance: Ultimately, choosing to perform HHUS-guided injection versus blind injection to treat trigger finger depends on the surgeon's experience and preference for a particular technique.

Accuracy of Wireless Hand-Held Guided Ultrasound Injections in the Trapeziometacarpal Joint: A Cadaveric Study.

Background Symptomatic trapeziometacarpal osteoarthrosis can be treated with an ultrasound-guided injection in the early stages. This cadaveric study aimed to assess the hypothesis suggesting enhanced accuracy and reliability of hand-held ultrasound (HHUS) injections compared to blind injections into the trapeziometacarpal joint (TMC). Materials and method Our series included 20 fresh cadaveric hands, with a total of 20 TMC randomly assigned to two groups. In group A, 10 TMC received a blinded injection, and in group B, 10 TMC received an ultrasound-guided injection with HHUS. Methylene blue was injected, and anatomical dissection was performed to assess the intra-articular location of the dye. The injection was considered accurate if the intra-articular synovial fluid was stained after opening the articular capsule on the dorsal approach. If there was no injection, it was inaccurate. A statistical analysis was performed, and p <.05 indicated a significant difference. Results Two thumbs were excluded during the study due to an existing trapeziectomy. In group A, 10 blind injections of TMC were performed, with 70% (7/10) of injections graded as accurate. In group B, eight ultrasound-guided injections were performed, with 75% (6/8) achieving accuracy. A Fisher's exact test was performed, and the results indicated no statistically significant difference in injection accuracy between the two groups (P = 1, odds ratio = 0.788). Conclusion Hand-held ultrasound guided TMC injections were not more accurate than blind injections performed by an experienced hand surgeon. Nonetheless, additional studies with a larger sample and comparative studies with conventional cart-based machines are necessary to evaluate the potential of this newly accessible device.

Semi-occlusive dressing versus surgery in fingertip injuries: A randomized controlled trial.

OBJECTIVES: No gold-standard treatment has been established for the management of distal digital amputation in Ishikawa zones II and III. The objective of this study was to compare the results of management of fingertip amputation by semi-occlusive dressing versus surgery. The principal hypothesis was that a semi-occlusive dressing results in better recovery of sensory function than a digital flap. METHODS: We conducted a prospective, randomized, multicenter study of 44 patients: 23 managed conservatively with semi-occlusive dressing, and 21 surgically with digital flap. RESULTS: Mean follow-up was 12 months. Mean healing time was 4.9 weeks in the semi-occlusive dressing group and 3.6 weeks in the surgery group. There was no significant difference between groups for sensory recovery of fine touch (p = 0.198) or 2-point discrimination (p = 0.961). No infections were reported in either group. Hook-nail deformity was more frequent in the semi-occlusive dressing group, particularly in case of amputation in zone III. CONCLUSIONS: Semi-occlusive dressing enabled satisfactory healing and sensitivity recovery without increasing the risk of infection. However, in zone III amputation, we advocate surgical treatment with a digital flap, due to poor trophicity and the frequency of hook-nail deformity seen with conservative management. LEVEL OF EVIDENCE: II.

Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review.

INTRODUCTION: Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS: A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA: 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA: non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS: The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION: TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.

Influence of surgical performance on clinical outcome after osteosynthesis of distal radius fracture.

INTRODUCTION: Clinical outcome after surgery depends on the surgeon's level of expertise or performance. The present study of minimally invasive plate osteosynthesis (MIPO) with anterior plate for distal radius fracture assessed whether clinical outcome correlated with surgeon performance. METHODS: The series included 30 distal radius fractures: 15 operated on by 4 level III surgeons (Group 1) and 15 by 4 level V surgeons (Group 2), utilizing the MIPO technique. The surgical performance of all 8 surgeons was assessed using the OSATS global rating scale. Clinical outcomes were assessed at 3 months' follow-up using the modified Mayo score (MMS), in 4 grades: 0-64 (poor), 65-79 (moderate), 80-89 (good), and 90-100 (excellent). The QuickDASH score (QDASH) was also calculated, and complications were recorded. RESULTS: Median MMS was better for level V (75 = fair result) than level III surgeons (62 = poor result). Median QDASH score likewise was better in group 2 (9.1) than group 1 (22.7). In group 1, there were 2 paresthesias in the median nerve territory, 1 type-1 complex regional pain syndrome, and 1 hypoesthesia in the scar area. Mean correlation between the 2 scores was -0.68. Group 1 patients were on average 7 years older. The number of patients, number of surgeons and distribution of OA A and C fractures were almost identical in the two groups. On MMS, the overall result of the two groups was moderate (70.5), which can be explained by short mean follow-up. DISCUSSION: Quality of the clinical outcome on MMS and QDASH increased with surgical performance, with fewer complications. In the patients' interest, protocols for improving surgical performance should be implemented, for example, through deliberate practice.

Preliminary stage in the development of an artificial intelligence algorithm: Variations between 100 surgeons in phase annotation in a video of internal fixation of distal radius fracture.

INTRODUCTION: In order to be used naturally and widely, an artificial intelligence algorithm of phase detection in surgical videos presupposes an expert consensus defining phases. OBJECTIVES: The aim of the present study was to seek consensus in defining the various phases of a surgical technique in wrist traumatology. METHODS: Three thousand two hundred and twenty-nine surgeons were sent a video showing anterior plate fixation of the distal radius and a questionnaire on the number of phases they distinguished and the visual cues signaling the beginning of each phase. Three experimenters predefined the number of phases (5: installation, approach, fixation, verification, closure) and sub-phases (3a: introduction of plate; 3b: positioning distal screws; 3c: positioning proximal screws) and the cues signaling the beginning of each. The numbers of the responses per item were collected. RESULTS: Only 216 (6.7%) surgeons opened the questionnaire, and 100 answered all questions (3.1%). Most respondents claimed 5/5 expertise. Number of phases identified ranged between 3 and 10. More than two-thirds of respondents identified the same phase cue as defined by the 3 experimenters in most cases, except for "verification" and "positioning proximal screws". DISCUSSION: Surgical procedures comprise a succession of phases, the beginning or end of which can be defined by a precise visual cue on video, either beginning with the appearance of the cue or the disappearance of the cue defining the preceding phase. CONCLUSION: These cues need to be defined very precisely before attempting manual annotation of surgical videos in order to develop an artificial intelligence algorithm. LEVEL OF EVIDENCE: II.

Technique, Indications and Limitations of a Minimally Invasive Approach to Treat Distal Radius Fractures and Malunions.

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. It offers the advantage of preserving ligamentotaxis, which facilitates the reduction and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intra-articular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

Methods of assessment of the level of surgeons for minimally invasive fixation of distal radius fractures: "expertise" versus "performance".

INTRODUCTION: The results of surgical techniques vary depending on the level of the surgeon's experience. The level of expertise can be evaluated quantitatively or qualitatively. In this study, we evaluated the duration of the procedure and the size of the incision of minimally invasive fixation of distal radius fractures as a means of grading expertise and surgical performance. The null hypothesis of our study was that the level of expertise did not match the level of performance. MATERIAL AND METHODS: The study included 52 surgeons split in five levels of expertise who had performed 467 minimally invasive fixations of distal radius fractures. The performance of the surgeons in terms of duration of the procedure and size of the incision were scored according to the five levels of surgical experience using four different methodologies: clinical (setting limits compared to data found in literature), statistical (setting statistical limits of comparison in percentiles (20th, 40th, 60th, 80th) for each of the two parameters measured), arithmetical (setting limits compared to equal intervals for each of the 2 variables), and success rate (setting a threshold for each of the 2 variables). RESULTS: Our results showed a great disparity between levels of experience depending on the method used. The scores for levels 1 and 2 were 72% for expertise, 13% for performance according to the clinical method, 75% for the statistical method, 0% for the arithmetical method, and 57% according the success rate. The rate of level 3 was 23% for expertise, 41% for performance by the clinical method, 17% by the statistical method, 17% by the arithmetical method, and 15% by the success rate. The rates of levels 4 and 5 were 5% for expertise, 46% for performance clinical method, 8% by the statistical method, 83% by the arithmetical method, and 28% by the success rate. DISCUSSION: The null hypothesis of our study was confirmed by the results which show that there was no correlation between levels of expertise and performance. The clinical method of assessment appears to reflect best the true level of performance of the surgeon. CONCLUSION: Publications reporting the results of a surgical technique for a given pathology should always mention the level of performance as measured on a clinical scale.

Pullout strength of connected pins in hand surgery: Effect of pin diameter and insertion angle.

OBJECTIVE: The purpose of this study was to examine the effect of insertion angles on the pullout strength of connected pins using a synthetic model simulating a hand bone. MATERIAL AND METHODS: The material consisted of Sawbones® (20 mm×20 mm × 60 mm), fixation pins secured to a connecting rod much like an external fixator, an electric drill (speed 1,290 rpm) and a tensile testing machine. The Sawbones® were drilled with different pin diameters (1.2 mm, 1.5 mm, and 1.8 mm) and insertion angles (100°, 110° and 120°). A vertical displacement of 1 mm/min was applied until the pins were extracted (maximum force). RESULTS: The pullout strength increased with the insertion angle of the connected pins. It also increased with their diameter. Regardless of the pin diameter, the load-displacement curve during the pullout test had 4 sections (peak 1, ascending slope, peak 2, descending slope) that corresponded to the combined frictional force and contact force between the pins and Sawbones®. DISCUSSION: Our study findings showed that, theoretically, for wrist or hand fractures treated with connected pins, the larger the diameter and insertion angle, the better the mechanical holding power of the pins. LEVEL OF EVIDENCE: I, experimental study.

Anterior plating technique for distal radius: comparing performance after learning through naive versus deliberate practice.

BACKGROUND: Surgical teaching is most often carried out in the operating theatre through mentorship, and the performance of surgical procedures is rarely measured. The objective of this article is to compare the progression in learning curves of junior surgeons trained in the anterior plating technique for the distal radius on a nonbiological model according to three different methods. METHODS: The materials comprised 12 junior surgeons of level 1 or 2 (as per Tang and Giddins) divided into three groups: control (G1), naive practice (G2), and deliberate practice (G3). The three groups watched a demonstration video of a level 5 expert. The four G1 surgeons (two level 1 and two level 2) saw the video only once, and each inserted five plates. The four G2 surgeons (two level 1 and two level 2) inserted five plates and watched the video before each time. The four G3 surgeons (two level 1 and two level 2) saw the video before the first plate insertion. Before posing the subsequent four plates, the four G3 surgeons watched their own video, and the expert indicated their errors and how to avoid them next time. A 12-criteria OSATS defined on the basis of the 60 videos, each graded from one (min.) to five (max.), was used to measure the objective surgical performance per plating (min. 12; max. 60) and per series of five plate fixations (min. 60, max. 300). RESULTS: The total average objective performance of G1 was 44.73, of G2 was 50.57 and of G3 was 54.35. Change in objective performance was better for G3 (13.25) than G2 (5) or G1 (3.75). For all groups, the progression in objective performance was better amongst level 1 surgeons (9) than level 2 surgeons (5.6). CONCLUSION: Surgical teaching is based on mentorship and experience. However, since "see one, practice many, do one" has started to replace "see one, do one, teach one", learning techniques have increasingly relied on procedure simulators. Against this background, few studies have looked at measuring the performance of surgical procedures and improved learning curves. Our results appear to suggest that deliberate practice, when used in addition to mentorship, is the best option for shortening the growth phase of the learning curve and improving performance. Deliberate practice is a learning technique for surgical procedures that is complementary to mentorship and experience, which allows the growth phase of the learning curve to be shortened and the objective performance of junior surgeons to be improved.